Healthcare Provider Details

I. General information

NPI: 1619251386
Provider Name (Legal Business Name): VICKI E RUSSELL LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2011
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PLZ
DAYTON OH
45404-1815
US

IV. Provider business mailing address

PO BOX 933421
CLEVELAND OH
44193-0039
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-4480
  • Fax: 937-641-5936
Mailing address:
  • Phone: 937-641-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1502367
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: